Neurotuberculosis immune reconstitution inflammatory syndrome in the setting of HIV infection: A case report and review of literature

Abstract

Immune reconstitution inflammatory syndrome (IRIS) is an exaggerated immune response which can occur with various coinfections in human immunodeficiency virus (HIV) infected patients, of which the most commonly implicated in central nervous system (CNS)-IRIS are progressive multifocal leukoencephalopathy (PML), cryptococcosis, and tuberculosis (TB). TB-IRIS is a known complication of pulmonary TB or TB lymphadenitis coinfection in HIV infected patients who are on antituberculosis treatment (ATT) after the initiation of antiretroviral therapy (ART). However, development of IRIS in extrapulmonary TB such as CNS TB is very rare. Our case is that of an isolated CNS-TB-IRIS, presenting as increase in the size and perilesional edema of the ring enhancing lesions in the brain, which was observed in two sequential magnetic resonance imaging done over a period of 2 months in a retropositive patient who presented with clinical deterioration after commencement of ART. As prompt diagnosis was made and specific management aimed at IRIS was started without delay, the patient improved symptomatically.

Clinical Reasoning: A Teenager With Chronic Meningitis—Does Occam's Razor Apply?

“…However, molecular diagnostics were negative for most infections, and this patient was young and immunocompetent without history or exposure to tuberculosis. Although immune reconstitution inflammatory syndrome 9 is still possible, atypical imaging features with microhemorrhages were less suggestive. Digital subtraction angiography for vasculitis was also unremarkable.Multicentric high-grade glioma or CNS lymphoma: normal perfusion and spectroscopy make glioma less likely.…”

Tuberculosis, human immunodeficiency virus, and the immune reconstitution inflammatory syndrome

“…For example, an HIV patient diagnosed with pulmonary TB and improving on anti-TB medications can develop worsening respiratory symptoms and appearance of new pulmonary lesions on radiologic imaging when he or she is initiated on ART. [ 22 28 ] In some cases, there could be new manifestations of TB at sites distant from the underlying pulmonary disease, for example, new lesions in the brain, eye, heart, or lymph nodes[ 29 30 31 32 ] There could be new clinical symptoms of a previously undiagnosed TB that manifest after initiation of ART. [ 8 28 ] In these cases, when the HIV-positive individual is initiated on ART, a few weeks later the patient develops new clinical manifestations leading to diagnosis of the apparently new TB infection.…”

“…For example, an HIV patient diagnosed with pulmonary TB and improving on anti-TB medications can develop worsening respiratory symptoms and appearance of new pulmonary lesions on radiologic imaging when he or she is initiated on ART. [ 22 28 ] In some cases, there could be new manifestations of TB at sites distant from the underlying pulmonary disease, for example, new lesions in the brain, eye, heart, or lymph nodes[ 29 30 31 32 ]…”

“…Researchers have tried to identify subsets of HIV- and TB-coinfected patients who are at increased risk of developing IRIS. Some of these risk factors include very low initial CD4 count, with a rapid rise in CD4 count after initiation of ART,[ 23 29 33 ] deregulation of T-cell responses,[ 20 34 35 ] and altered ratios of various cytokines. [ 22 36 37 ] These studies may be tantalizing to research scientists.…”

“…Laboratory studies that support the diagnosis include evidence of a rapid rise in CD4 count and associated fall in viral load. [ 23 26 29 33 ]…”